Essential tremor develops insidiously and progresses slowly.  May start in a single limb, but it becomes bilateral over time.  Flexion-extension movement of the wrist, frequency of 4 to 12 Hz. May involve head (yes-yes or no-no).Worsens with stress, fatigue, and may increase with some voluntary activities eg holding a fork or cup. Rest, beta blockers, and alcohol help.  Often a family history.

Compare Cerebellar tremor – low-frequency (less than 5 Hz), intention tremor.  May include postural element (ie at rest).  Other signs include abnormalities of gait and speech, nystagmus, dysdiadochonesis (inability to perform rapid repeated hand movements).  Titubation is the word given to rhythmic movements of head/neck seen in cerebellar disease.

So ask patient to extend arms.  Do Finger-to-nose, finger-to-finger, and heel-to-shin testing (Cerebellar).  Observe drinking from glass, writing name, drawing spiral (or draw within lines of pre-printed spiral).  Check for tone (rigidity), esp when busy using other limb, eg draw a circle in the air) – basal ganglia, eg Parkinsons. Check gait (shuffling?  Ataxic?), eye movements.

Look for signs of space occupying lesion, thyroid or liver disease.  Any chance of intermittent hypoglycaemia?  Panic disorder?  Withdrawal?